CurrentCapital BluecrossPolicy MP 2.389

Intraocular Radiotherapy for Age-Related Macular Degeneration

This policy governs coverage for intraocular radiation therapies (brachytherapy, proton beam therapy, stereotactic radiotherapy) for choroidal neovascularization due to age-related macular degeneration for Capital Blue Cross products, with program-specific benefit variations.

Policy Summary

PayerCapital Bluecross

PolicyIntraocular Radiotherapy for Age-Related Macular Degeneration

Policy CodePolicy MP 2.389

Change TypeNo material change

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify member benefits and eligibility and contact Provider or Member Services as needed before proceeding.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1procedure code listed as investigational / not covered

No FDA-approvedNo FDA-approved devices

RCTsPhase 3 RCTs cited

NICE 2011guidance / regulatory note

Coverage Criteria

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Investigational / Not Medically Necessary

The following interventions for choroidal neovascularization are considered investigational (not medically necessary):

Intraocular placement of a radiation source (brachytherapy)

Proton beam therapy

Stereotactic radiotherapy

No devices are specifically approved by the U.S. Food and Drug Administration (FDA) for intraocular radiation. An investigational device exemption was granted by the FDA for a phase 3 multicenter trial of the EPI-RAD90™ (now known as Vidion Anti-Neovascular Epimacular Brachytherapy [EMBT] System; NeoVista) to provide data for a device application to the FDA. This is a category B procedure.

Brachytherapy, proton beam therapy, and stereotactic radiotherapy for choroidal neovascularization due to age-related macular degeneration are considered investigational. Randomized trials and reviews have not demonstrated improvement in net health outcomes (visual acuity, functional outcomes, quality of life) and have shown higher adverse events or no significant benefit in key outcomes compared with standard therapy.

Procedure Codes considered investigational / therefore not covered: 67299

Administrative update: Benefit Variations section was removed from the policy. No explicit separate exclusions appear in this section.

Provider Actions and Billing Guidance

Billing Rule

Billing rule: Code 67299 listed as investigational / not covered

Procedure code 67299 is identified in the coding section as investigational and therefore not covered. Identification of a code in this section does not guarantee coverage — coverage is determined by the member's benefit terms.

Affected code: CPT 67299 — investigational / not covered

Prior Authorization

Prior authorization

No prior authorization requirements are specified in the provided policy sections. Providers should follow member benefit terms and any plan-specific utilization management rules; when in doubt, verify with the payer.

No explicit prior authorization process or PA codes described in policy content provided
Prior authorization, if required, is governed by member benefit information and plan programs

Documentation Required

Benefit verification required

Providers must verify member eligibility and benefits and contact Provider Services or Member Services for coverage determinations. Medical policy determinations do not guarantee payment; final claim payment is subject to the member's contract.

Verify member benefits and eligibility on date of service
Contact Capital Blue Cross Provider Services or Member Services for questions

Note

Clinical evidence and documentation

Clinical trials, randomized controlled trials, and guideline-level evidence are cited in the policy; however, the policy does not include a specific documentation checklist (for example, required imaging or clinical notes) to support medical necessity.

Evidence present: randomized trials and feasibility studies for epimacular brachytherapy, proton beam, and stereotactic radiotherapy
No policy-specified documentation checklist (e.g., required OCT or fluorescein angiography elements) included

Note

Standard therapy precedence

Intravitreal anti-VEGF therapies (pegaptanib, ranibizumab, bevacizumab, aflibercept) are described as the standard of care for neovascular age-related macular degeneration; intraocular radiation approaches are investigational alternatives.

Standard therapy precedence: Intravitreal anti-VEGF agents are usual care
Investigational alternatives: intraocular brachytherapy, proton beam, stereotactic radiotherapy — considered investigational and not covered

Step Therapy

Step therapy

The policy does not describe any step therapy requirements or a required treatment sequence prior to use of the investigational therapies. Providers should not assume any step-therapy pathways are defined by this policy; follow product-specific benefit rules if present.

No step therapy or required treatment sequence described in the policy text provided
If step therapy is required by the member's benefit, follow the plan's utilization management procedures

Denial Risk

Investigational therapies not covered

Investigational therapies listed in the policy (intraocular placement of a radiation source/brachytherapy, proton beam therapy, stereotactic radiotherapy) are considered investigational and therefore not covered under this medical policy.

Not covered (investigational): intraocular brachytherapy, proton beam therapy, stereotactic radiotherapy

Note

No explicit denial triggers stated

The provided policy excerpts do not state explicit denial triggers (for example, specific clinical findings that will cause automatic denial). Use clinical criteria, member benefit terms, and utilization management processes to determine coverage decisions.

No explicit automatic denial criteria are specified in these policy sections
Coverage decisions remain subject to member contract terms and medical necessity determinations

Definitions

Intraocular radiotherapy

Brachytherapy (intraocular/epiretinal)Delivery of a localized radioactive source (eg, strontium-90) to a subfoveal choroidal neovascular lesion via a vitrectomy-assisted cannula; NeoVista Epi‑Rad90 example delivers a one-time peak beta dose of 24 Gray to a target region (≈3 mm depth, up to 5.4 mm diameter).

Proton beam therapyExternal charged-particle radiotherapy using protons (or helium ions) that deposits ionizing energy at precise depths (Bragg peak) to concentrate dose at the target while minimizing exit dose to adjacent tissues.

Stereotactic radiotherapyNon‑surgical, robotically controlled external beam delivery through the sclera to overlap beams at the macula, producing a focused dose to neovascular AMD lesions in an office setting.

Epiretinal (macular) brachytherapy

DefinitionLocalized placement of a radioactive source on the epiretinal (macular) surface to irradiate choroidal neovascularization, typically delivered via a vitrectomy procedure with a handheld cannula advancing a strontium‑90 source to the lesion site.

Clinical contextInvestigated as an adjunct or alternative to intravitreal anti‑VEGF therapy for neovascular AMD; evaluated in randomized trials and feasibility/observational studies (eg, CABERNET, MERITAGE, MERLOT).

Device/dose exampleNeoVista Epi‑Rad90 system: single application delivering a peak beta particle dose of 24 Gray to the target area (3 mm depth, up to 5.4 mm diameter).

Stereotactic radiotherapy

DefinitionFocused external beam radiotherapy delivered with stereotactic techniques to overlap beams at the macula, targeting neovascular AMD lesions without intraocular device placement.

EvidenceSafety and efficacy outcomes reported from the INTREPID randomized trial (52‑week and year‑2 results) and subsequent real‑world/observational studies; INTREPID cited as primary RCT evidence for stereotactic radiotherapy.

Delivery settingTypically performed as a nonsurgical, office‑based procedure using a robotically controlled system to direct beams through the sclera to the macula.

OpenPayer

Intraocular Radiotherapy for Age-Related Macular Degeneration

Coverage Criteria

Coding

Provider Actions and Billing Guidance

Background

Definitions

Revision History